Contemporary utilization trends and survival outcomes in patients undergoing radical cystectomy and bladder preservation therapy for muscle invasive bladder cancer.

Abstract

387 Background: To compare overall survival (OS) in patients undergoing radical cystectomy (RC) and bladder preservation therapy (BPT) for muscle invasive urothelial carcinoma of the bladder. Methods: We conducted a retrospective, observational cohort study in which we reviewed the National Cancer Database (NCDB) to identify patients with analytic stage II-III (N0M0) urothelial carcinoma of the bladder from 2003-2011. BPT patients were stratified as any external beam radiotherapy (EBRT), definitive radiotherapy (RT) [50-80Gy], and definitive RT + chemotherapy. Treatment trends were evaluated using Pearson Chi-square tests. OS was compared between RC and BPT using unadjusted Kaplan Meier curves and Cox regression models adjusted for year of treatment, hospital volume, and patient/tumor characteristics using increasingly stringent selection criteria to identify those undergoing BPT. Results: Of the 603,298 patients with bladder cancer captured in the NCDB from 2003-2011, 9% (n = 54,518) had analytic stage II-III with urothelial histology. 51.1% (n = 27,843) of these patients were treated with RC (70.9%, n = 19,745) or BPT (29.1%, n = 8,098). Of the patients undergoing BPT, stratified by selection criteria, 26.9% (n = 2,176) and 15.0% (n = 1,215) were treated with definitive RT and definitive RT + chemotherapy, respectively. Following adjustment, improved survival in patients undergoing RC was noted regardless of BPT definition employed in multivariate analysis. However, we noted attenuated differences in OS using increasingly stringent definitions for BPT (EBRT: HR 2.2 [CI 2.15-2.29]; definitive RT: HR 1.94 [CI 1.74-2.14]; definitive RT + chemotherapy: HR 1.56 [CI 1.45-1.68]). Conclusions: In the NCDB, receipt of BPT was associated with decreased OS compared to RC in all patients with stage II-III urothelial carcinoma, in part due to selection biases. However, the use of increasingly stringent definitions of BPT attenuated the observed survival differences. Further randomized prospective controlled trials are needed to compare trimodal BPT to RC to identify optimal candidates for bladder preservation.

Bladder Preservation Therapy: A Review of the Literature and Future Directions

“…38 Improved OS in patients undergoing RC was noted regardless of BPT definition used following adjustment. 38 38 These cohort analyses elucidate that careful patient selection may provide similar survival outcomes after accounting for measured and unmeasured confounding biases when comparing BPT to RC. 37,38 The authors recognize the shortcomings of BPT, including the utilization of clinical staging, which is considered inferior to RC pathologic staging.…”

“…38 38 These cohort analyses elucidate that careful patient selection may provide similar survival outcomes after accounting for measured and unmeasured confounding biases when comparing BPT to RC. 37,38 The authors recognize the shortcomings of BPT, including the utilization of clinical staging, which is considered inferior to RC pathologic staging. Agreement between clinical and pathologic staging was demonstrated in only 35.7% of patients in a 2006 multi-centered international series.…”

“…37 In comparison, a recent study examined approximately 27,000 patients with analytic stage II-III urothelial carcinoma from the NCDB from 2003-2011. 38 BPT patients were stratified into the following cohorts: 1) any external beam radiotherapy 2) definitive radiotherapy (defined as 50-80Gy), and 3) definitive RT with chemotherapy. 38 Improved OS in patients undergoing RC was noted regardless of BPT definition used following adjustment.…”

“…38 BPT patients were stratified into the following cohorts: 1) any external beam radiotherapy 2) definitive radiotherapy (defined as 50-80Gy), and 3) definitive RT with chemotherapy. 38 Improved OS in patients undergoing RC was noted regardless of BPT definition used following adjustment. 38 38 These cohort analyses elucidate that careful patient selection may provide similar survival outcomes after accounting for measured and unmeasured confounding biases when comparing BPT to RC.…”

Biomarkers for Predicting Clinical Outcomes of Chemoradiation-Based Bladder Preservation Therapy for Muscle-Invasive Bladder Cancer

“…There is no randomized controlled trial comparing outcomes between BPT and RC in MIBC patients. Recently, 3 studies retrospectively compared prognosis of MIBC patients between BPT and RC using a propensity score matching analysis: 2 studies derived from the National Cancer Database (NCD) [18,19] and one study from a Canadian multidisciplinary bladder cancer clinic [20]. The 2 NCD studies demonstrated more favorable OS for RC than that for BPT.…”